736 July 1989 Vol. 40 No. 7 Hospital and Community Psychiatry

Acknowledgments

The author thanks Francine Cournos,M.D., Maureen Empfield, M.D., EwaldHorwath, M.D., and Martin Kramer,M.D., for information about the mcdi-cal and psychiatric aspects of HIV, andRobin Goldman, J.D., for assistance indeveloping the legal analysis.

References

1. Kelley KV: AIDS and ethics: an oven-view. General Hospital Psychiatry9:331-340, 1987

2. Gosten L: Public health strategies forconfronting AIDS: legislative and regu-latory policy in the United States.JAMA 261:1621-1630, 1989

3. Binder R: AIDS antibody tests on in-patient psychiatric units. American jour-nal of Psychiatry 144: 176-181, 1987

4. Article 4419b-1, Vernon’s Texas CivilStatutes, Section 9.02 (1987)

5. 146.025 (2)(a), Wisconsin Statutes(1987-1988)

6. Guardianship of Anthony, 402 Mass723 (Sup Ct Mass, 1988)

7. Centers for Disease Control: Update:universal precautions for prevention oftransmission of human immunodefi-ciency virus, hepatitis B virus, and otherbloodborne pathogens in health caresettings. Morbidity and MortalityWeekly Report 37:377-382, 1988

8. Section 413, New York Social ServiceLaw (McKinney, 1978)

9. AIDS policy: guidelines for inpatientpsychiatric units. American Journal ofPsychiatry 145:542, 1988

10. Gostin L, Curran WJ: 1.egal control mea-sunes for AIDS: reporting require-ments, surveillance, quarantine, and negu-lation of public meeting places. Amen-can Journal of Public Health 77:214-

218, 19871 1. Gniswald v Connecticut, 381 US 479

(1966)12. Rehabilitation Act of 1973, 29 USC

701 (1973)1 3. Tarasoff v Regents of the University

of California, 551 P2d 334 (Cal SupCt, 1976)

14. Naidu v Laind, 539 A2d 1064 (DelSup Ct, 1988)

15. Holbrook T: Policing sexuality in a mod-cnn state hospital. Hospital and Com-munity Psychiatry 40:75-79, 1989

16. Cournos F, Empfield M, Honwath E,et al: The management of HIV infec-tion in state psychiatric hospitals. Hos-pita! and Community Psychiatry40:153-157, 1989

17. Article 27-F, New York Public Health

Law (McKinney, 1988)18. Centers for Disease Control: Recom-

mendations for prevention of HIV trans-mission in health-care settings. Mor-bidity and Mortality Weekly Report36:15-17, 1988

19. Gloven v East Neb Comm, Office ofRetardation. 686 F Supp 243 (DC Neb,1988)

20. Doe v County of Cook, Illinois (DCN Ill 87-C-68888, Feb 24, 1988)

2 1. School Board of Nassau County v An-line, 94 L ED 2d 307 at 318.319(1987)

22. APA position statements outline roleof psychiatrists in combating fear ofAIDS. Hospital and Community Psy-chiatry 38:433, 1987

23. Appelbaum PS: AIDS, psychiatry, andthe law. Hospital and Community Psy-chiatry 39:13-14, 1988

24. Cournos F, Horwath E: ConfiningAIDS Patients (ltn). Hospital and Com-munity Psychiatry 39:671, 1988

Involuntary Medicationand the Case of Joyce Brown

Francine Cournos, M.D.

In October 1987, Joyce Brown be-came the first homeless person re-moved from New York City’sstreets and hospitalized under acity initiative that authorizedevaluation of “gravely disabled”homeless pensonsfor admission toinpatient psychiatric treatment.

Miss Brown’s highly publicizedand ultimately successful count bat-tie to prevent a course of forced

Dr. Cournos is assistant clinicalprofessor of psychiatry at Co-lumbia University College ofPhysicians and Surgeons anddirector of the WashingtonHeights Community Service ofthe New York State PsychiatricInstitute, 722 West 168th Street,New York, New York 10032.

medication is described. Her re-fusal of medication was upheldbased on hen capacity to under-

stand the proposed treatment andto express a partially rational

opinion about it. The author,who served as independent psy-chiatnic consultant to the courton the decision about MissBrown’s involuntary medication,uses the case to illustrate someofthe problems ofinvoluntary psy-chiatnic intervention, includingthe commitment of competent pa-tients and the lack ofa coherent

approach to persistent treatmentrefusal.

The problem of involuntary treat-ment recently received worldwide

attention when a patient namedJoyce Brown challenged NewYork City’s widely publicized plan

to forcibly hospitalize and treat

mentally ill homeless people whowere living on the streets and me-

fusing mental health services.In October 1987, a team of

mental health workers from Pro-

ject HELP were authorized by aliberalized interpretation of NewYork State’s long-standing civil corn-mitment statutes to remove cer-tam “gravely disabled” individualsfrom the streets (1). These mdi-viduals were to be brought toBcllcvue Hospital, where theycould be evaluated for admissionto a special psychiatric ward. JoyceBrown was the first homeless pen-

son to be hospitalized as a resultof the Project HELP initiative.Rarely has a case of involuntarypsychiatric intervention inspiredsuch wide public attention, sug-

gesting that the public has becomeincreasingly interested in whether

forced psychiatric care is the

Hospital and Community Psychiatry July 1989 Vol. 40 No. 7 737

proper response to certain kinds

of homelessness.I acted as independent psychi-

atnic consultant to the count onthe decision of whether JoyceBrown, a committed patient, could

be subjected to a course of invol-untaily administered antipsychoticdrugs. In this paper I examinesome of the issues and conflictsinvolved in that decision.

Case developmentsJ oyce Brown’s hospitalization.Joyce Brown, who initially identi-fled herself as Billie Boggs, was a40-yea-old single black womanwho had been living on the streets

of an affluent Manhattan neigh-bonhood for a yea and a half,panhandling to get enough moneyfor food. On October 28, 1987,

she was picked up by ProjectHELP (2). She was taken to

Bellevue Hospital’s emergencyroom, committed at Bellevue, andadmitted to the special unit for

the homeless.Popular attention was focused

on two questions. First, was JoyceBrown homeless because she waspoor or because she was mentallyill? And second, should we praise

the efforts of the city to removeher from her debased cimcum-

stances on support her struggle toassert hen individual rights in the

face of overwhelming state power?But while the media focus on Joyce

Brown may have made hem appeartypical of the homeless mentallyill entering New York City’s newprogram, her case was in fact notrepresentative at all. She was prob-ably less impaired than mostchronic mentally ill persons. Shewas also virtually unique in her

capacity to reconstitute herself (3).Legal proceedings. Miss

Brown’s case became the objectof three widely publicized courtproceedings during which hen coun-sd, on hem behalf, waived all ofher rights of confidentiality. Thusthe information in this paper aboutMiss Brown comes from the pub-

lic record.On October 29, 1987, Miss

Brown petitioned for a hearingto protest hen commitment. At thesubsequent series of hearings, two

entirely different accounts of hersituation emerged. Lawyers for the

city and their psychiatric expertsargued that Miss Brown had schizo-phncnia, was delusional, and ne-quined hospitalization because sherepresented a danger to herselfby virtue of self-neglect, pro-vocative behavior, and suicidal im-

pulses. Miss Brown’s lawyers, whowere members of the New YorkCivil Liberties Union (NYCLU),

and their psychiatric consultantsasserted that Miss Brown did nothave a serious mental illness, butwas a “professional street person”whose difficulties on the streetwere a natural consequence of be-ing homeless. They pointed to her

ability to survive on the streetswithout harming herself or other

people.

The two accounts ofMiss Brownwere as different as her own ap-

pearancc under varying cincum-stances. On the streets, she wasdirty, disheveled, malodorous, hos-tile, and verbally abusive. In court,

she was well-groomed, in control,logical, coherent, and even witty.

The trial judge, faced with en-timely contradictory testimony bypsychiatrists, gave considerableweight to Miss Brown’s national

demeanor and testimony at thetime of the hearing. He ruled thatshe did not meet the standard for

commitment and ordered her me-leased on November 12, 1987 (4).

The city immediately appealed thisdecision, and Miss Brown mc-maimed hospitalized during the ap-peal. On December 18, 1987, ina 3-to-2 decision, the appellatedivision of the state supreme courtreversed the trial count and up-held her commitment, citing the

failure of the trial judge to givesufficient weight to the testimonyof the treating psychiatrists (5).

Miss Brown’s hospitalization wascontinued, but she had consistentlyrefused medication. In New YorkState, since the Rivers vs. Katz

decision (6), all nonemengency de-cisions about the involuntary ad-ministration of antipsychotic drugs

to committed patients must bemade by a judge. So the city re-turned to count for the third time,seeking judicial authorization to

administer a three-week trial ofhalopenidol. The remainder of this

paper concerns this attempt to in-voluntarily medicate Joyce Brown.

Joyce Brown’s illness. In JoyceBrown’s commitment hearing andthe hearing about her involuntarymedication, the count approachedthe problem by first attemptingto determine the extent of MissBrown’s mental illness. However,her case was especially perplexingbecause a satisfying answer to thisquestion was to remain perma-nently beyond reach.

Miss Brown’s first known con-tact with the psychiatric systemwas a single previous two-weekhospitalization in 1985. Her ad-mission diagnosis had been atypi-cal psychosis, rule out paranoidschizophrenia; her discharge diag-nosis was paranoid personality dis-

order. Before that hospitalization,

however, she had a 20-yea his-tony of drug abuse, including useof cocaine and intravenous heroin.She had worked for many yearsas a secretary, but stopped work-ing and received Social Security

disability benefits after the 1985hospitalization. She never resumedher previous level of functioningand became homeless in April1986, after relatives were no

longer able to care for her.Repeated observations were

made during hen hospitalizationsthat Miss Brown was hostile, yen-

bally abusive, socially isolated, andresistant to treatment. Numerousinstances of screaming, yelling, curs-ing, agitation, and threatening physi-cal gestures toward staff and pa-ticnts were documented. She had

appeared similarly belligerent tothe mental health workers who

observed hem on the streets. Forexample, she cursed at passersby,became angry at offers of help,and exposed hen nude buttocksto the outreach psychiatrist. Inter-mittently she displayed evidenceof a thought disorder, such as talk-ing in rhymes and offering imnele-vant answers.

However, city psychiatrists wereunable to prove convincingly thatMiss Brown was psychotic. Her

evasive and somewhat incredibleexplanations for her behavior did

738 July 1989 Vol. 40 No. 7 Hospital and Community Psychiatry

not provide definitive evidence ofthe delusions or hallucinations char-actenistic of psychosis. For exam-

plc, she burned and tore moneywith the explanation that themoney had been offered in a con-

descending manner and that, inany case, keeping money on thestreets was dangerous. She talkedand laughed to herself but deniedthat she was responding to voices.

Since she was national and lucid

in count, she may have never beenseriously psychotic. On the otherhand, hen psychosis may have im-

proved in the hospital even with-out medication, on she may in facthave been psychotic but may alsohave had the desire and ability to

conceal her symptoms.As for the question of hen danger-

ousness, Miss Brown consistentlydenied suicidal and homicidal idea-

ton. She explained that her made-quate clothing and hygiene werethe consequences of poverty and

homelessness. She denied that shehad been trying to harm herselfduring the one occasion when Pro-

ject HELP staff observed hen walk-ing into traffic. She stated that her

resort to verbal abuse was neces-

say to fend off unwanted offersof help.

Joyce Brown’s capacity. Whileit wasn’t possible to determine theprecise extent of Miss Brown’smental illness, the Rivers decisionoffered a way to arrive at a dcci-sion about involuntary medication

by weighing other issues. Accord-ing to Rivers, the legal standardfor authorizing involuntary treat-ment involves two elements.

First, the state must demonstrate“by clear and convincing evidence”

the patient’s incapacity to make atreatment decision. In the absenceof such incapacity, the patient hasthe right to refuse treatment, nomatter how beneficial. Second, ifthe patient is determined to lackcapacity, the state must show that“the proposed treatment is nan-

rowly tailored to give substantialeffect to the patient’s liberty in-terest, taking into consideration

all relevant circumstances, includ-ing the patient’s best interests, thebenefits to be gained from the

treatment, the adverse side-effectsassociated with the treatment, andany less intrusive alternative treat-ments” (6).

If Miss Brown had the capacityto make her own treatment dcci-sion, she clearly had the night torefuse medication. In consideringher case, the distinction between

Too little is known

to conclude that a

course of medication

in the hospitalleads to long-term

improvement and

compliance after

discharge.

a mental status examination, in-tended to provide a global picture

of the patient’s psychiatric func-

tioning, and an assessment of ca-pacity, which is a more narrowlyfocused evaluation, becomes im-portant. This distinction is fnc-

quently overlooked by clinicians(McKinnon K, Cournos F, Stanley

B, unpublished paper, 1989).

Many authors in the legal and

psychiatric literature have accepteda definition of capacity based on

four tests that form a hierarchy.Each of the four tests provides a

stricter standard of decision-making ability. These four testsarc evidencing a choice, factualunderstanding of the choice, na-tional reasoning, and appreciation

(7,8).Miss Brown was able to pass

the first three tests of capacity.She knew she had a decision tomake concerning her treatment.Hen knowledge of the proposed

medication rivaled that of a first-year psychiatric resident. She knewthe name, class, side effects, and

purpose of the proposed drug. Thereasons she offered for refusing

the medication were rational andnonpsychotic. She doubted its ef-fectiveness in hen case, disliked

the side effects, and was wary ofall mind-altering drugs because ofher past history of addiction.

However, Miss Brown failed thelast and strictest test of capacity,appreciation. Both the city and

the NYCLU agreed that MissBrown had impaired insight andpoor judgment about the conse-

quences of her behavior. Sheviewed all of her own actions asa realistic response to external cm-cumstanccs and could not under-

stand why others would attemptto forcibly treat hem.

This brings us to an interestingpoint-capacity is not an all-or-nothing phenomenon. At the cx-

tremes, capacity requires as little

as a patient’s ability to offer ayes-or-no answer to a proposedtreatment on as much as an assur-

ance that no pathological emotionalor motivational pressures influencehis decision (9,10).

The Rivers decision suggests that

when capacity is present, the courtneed not examine the merits of

treatment. In these instances, onlythe patient, applying his own val-ucs, can determine if the treat-ment proposed for him is appno-

pniate. In practice, however, ca-pacity cannot be examined sepa-

rately from the proposed treat-ment because tests of capacity arc

adjusted to the risk-benefit ratio

of the intervention under consid-cration (1 1). If the benefits arelimited, such as taking aspirin fora headache, or the risks arc great,such as accepting a heart trans-plant, very little capacity is neededto successfully refuse treatment.Therefore, whether Miss Brownhad sufficient capacity to refusean antipsychotic drug dependedin part on the benefits and risks

of drug treatment in her case.Benefits of treatment. The city

acknowledged that Miss Brown’sbehavior had become more organ-ized within the first few days ofhospitalization and that hen situ-

ation was not acute. Therefore,the benefits of medication wouldnot be in managing a crisis, but

rather in treating an ongoing con-dition.

Miss Brown had cleanly beenchronically hostile, irritable, andverbally abusive. In unstructuredsituations she often behaved in a

Hospital and Community Psychiatry July 1989 Vol. 40 No. 7 739

primitive, regressed, and sociallyaberrant manner. She appeared toprovide incomplete informationabout hen internal state, but the

behavioral picture was compatiblewith a diagnosis of a serious men-tal illness, either schizophrenia ormanic-depressive disease. MissBrown had never received an ade-

quate course of antipsychoticdrugs, whose likely benefits wouldbe to diminish hen symptoms andimprove her functioning. More-over, no alternative treatmentswere available that would be likelyto ameliorate her symptoms.

The city lawyers had empha-sized Miss Brown’s potential danger-ousness. Reducing dangerousnessoften weighs heavily in a court’s

consideration of a treatment’s bene-fits. Yet the evidence for signifi-

cant danger to herself on otherswas weak.

Risks of treatment. In examin-ing risk, courts primarily take intoaccount the serious side effects

of psychotropic medications. Manycourts have emphasized the intru-sive nature of these medications.

The court’s focus on risks is inobvious contrast to that of physi-

cians, who emphasize the benefitsof treatment (12).

Moreover, since antipsychotic

drugs ameliorate symptoms ratherthan cure illness, the risks of side

effects extend over the indefiniteperiod of time that the drugs mustbe used. Another risk is that coem-cion may result in short-term treat-ment at the cost of the patient’slong-term cooperation. Physicians

maintain the hope that refusal oftreatment is a symptom, which willimprove along with the illness it-

self. However, too little is knownto conclude that a course of invol-untary medication in the hospitalleads to long-term improvementand compliance afterdischage(1 3).When the patient does not ulti-mately agree that the treatmentwas beneficial, he may be resentfuland reluctant to have further con-

tact with the mental health system.How did these issues apply to

Miss Brown’s case? Little was

known about Miss Brown’s me-

sponsc to medication. Her total

exposure to antipsychotic drugsinvolved a single emergency dose

of 5 mg of intramuscular halopeni-dol on the day of admission toBcllcvuc and brief treatment with

chlorpromazine during her 1985hospitalization. She reported thatthese medications were very un-pleasant; they made her feel

sleepy, light-headed, and less ableto think. She connected thisdysphoric response to unpleasantmemories of her long period ofdrug addiction. Moreover, sheprided herself on hen indepen-dence. Her stubborn refusal toaccept medication could thus havebeen charactenological and notbased on her primary mental ill-

ness.Timing of treatment. Miss

Brown’s condition was neither me-

cent non emergent, and thereforea separate question arose aboutdelaying a course of medication.Miss Brown had constructed a dis-charge plan of her own, which

included residing in a Midtownhotel and receiving various kindsof practical help from her lawyers.

The less aggressive option could

be tried first, with the understand-ing that the more intrusive treat-ment-medication-could be un-

dertaken later if these conserva-

tive measures failed.The consultant’s recommenda-

tion. As independent psychiatricconsultant, I based my recommen-dations on the finding that Joyce

Brown had partial capacity to makethe treatment decision. I believedthat Miss Brown had a mental

illness that would benefit from mcdi-cation and that there were no lessintrusive treatments that were

likely to be effective. Miss Brownengaged in risk-taking behaviors,but neither she non others hadcome to serious physical ham inthe past, and the risks she tookwere not extreme.

I believed that Miss Brown’santipathy to treatment was likelyto be increased by coercion andthat she would discontinue the mcdi-cation once she left the hospital.She would therefore be likely to

have significant difficulties after

discharge with or without a course

of medication in the hospital.Given Miss Brown’s fairly good

capacity and the moderate risk-benefit ratio of involuntarily ad-ministered antipsychotic drugs, Irecommended that Miss Brown at-tempt her own dischage plan with-

out receiving medication. If sherequired rehospitalization, perhapsa better case could be made atthat time that medication was nec-essary to her survival in the corn-munity.

The judge’s ruling. On January15, 1988, Judge Irving Kirschen-baum and I deliberated for oventwo hours, carefully contrasting thepossible outcomes of medicating

Joyce Brown with the possible con-sequences of allowing hem to leavethe hospital without having beenmedicated. The Judge and Ireached a consensus that MissBrown’s refusal of medicationshould be supported. Taking intoaccount my findings, Judge Kinsch-enbaum ruled that Joyce Brown

had the capacity to make a rca-soned decision and upheld herwish to refuse medication (14).

He cited her rational objectionsto medication and the lack of con-vincing evidence for dangerous-ness. He was not persuaded that

the medical benefits would out-weigh the negative effects of acourse of involuntarily admini-

stered haloperidol.Hospital discharge. Four days

later, after a 1 2-week hospital stay,

hen treating physician dischargedMiss Brown, stating that withoutmedication she would receive no

further benefit from continued hos-pitalization (15). Miss Brownmoved into a room in a Midtown

Manhattan residence for homelesswomen that offers onsite mealsand the services of a mental health

team.In the months after her dis-

charge, the press continued to re-port the apparently contradictoryaspects of her behavior. For exam-pie, she was a guest speaker at

Harvard Law School on February18, 1988, but two weeks later shewas panhandling and cursing on

the streets (16). She was arrestedfor heroin possession in Septem-

740 July 1989 Vol. 40 No. 7 Hospital and Community Psychiatry

bem 1988 and in January 1989 shewas reported to be temporarily

back on her accustomed street con-

ncr (17).

DiscussionJoyce Brown’s case illustrates someof the ongoing controversies aboutthe use of coercion in responseto treatment refusal. In New YorkState, as in almost all other states(18), an incompetent refusal oftreatment is not required for com-mitment. A standard requiring in-competent refusal of treatment forcommitment is found in the APAmodel law on civil commitment,and its application might signifi-

cantly restrict the number of pa-tients who could be committed (19).

Miss Brown’s refusal of medica-tion was upheld based on her ma-

tional and lucid testimony. Thisresult is uncommon among com-mitted patients. However, if corn-mitment required the incompetentrefusal of treatment, such a situ-ation would be even less likely to

occur. But problems would me-main, including the definition of

capacity and the fluctuations inany particular patient’s capacity.

Such problems are apparent inMiss Brown’s case because her ca-pacity appeared to improve be-

twcen the time of her commit-ment and the court hearing abouther medication.

The Brown case also tells usabout the limits of coercion in amental health system that has shiftedthe locus of care from the hospital,where involuntary treatment is readi-ly undertaken, to residential andoutpatient care, where patient co-operation and responsibility areessential. Such a system is poorlyequipped to respond to large num-bers of individuals who are unableto accept needed services.

Committed patients have theirobjections to medication ovennid-den 67 to 100 percent of the time(13). While it is easy to win the

battle over medication with a hos-pitalized patient, the same patientcan almost always avoid treatment

after discharge. Noncompliancerates among outpatients who take

antipsychotic drugs exceed 40 per-cent (20).

Therefore it is misleading toview treatment objections solely

from an inpatient perspective. Even

if Miss Brown had been involun-taily medicated, she would stillhave been free to decide abouther own treatment after leavingthe hospital. If Miss Brown in-deed had a life-long illness such

as schizophrenia, a short-term so-lution was less important than along-term plan. Persistent medica-

tion refusal among the seriouslymentally ill can result from im-painrncnts in the capacity for self-

observation (the appreciation stan-dard of capacity), co-morbiditywith substance abuse or character

pathology, a poor therapeutic ne-sponse to drugs (2 1), and intoler-

able side effects of medication (22).These problems have no simple

solutions. Long-term efforts arerequired to engage patients in treat-ment and find acceptable strate-

gies for their care (23).

Miss Brown’s dramatic hospi-

talization and the accompanyingevents were temporarily effectivein allowing her to accept place-ment in a home. Eliciting more

complete and longer-term coop-enation is another matter. In thisregard, the unusually articulate

Miss Brown typifies the problems

of the disaffiliated homeless.

Acknowledgments

The author thanks Stephan Haimowitz,J.D., and Karen McKinnon, M.A.

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